Malaysia’s Mental Health Workforce Under Pressure

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On April 2nd, remarking on the quality of Malaysia’s mental health services, Health Ministry deputy director general Datuk Dr Jeyaindran Sinnadurai noted that most mental health departments are currently overburdened and understaffed. [1]

Compared to a decade ago, these facilities now face a much larger caseload burden. Datuk Dr Jeyaindran also highlighted the issue of an understaffed mental health workforce, and the ministry’s efforts to look into the issue.

Shortage of qualified mental healthcare professionals

In Malaysia, the shortage of core mental health professionals is a serious barrier to achieving optimal mental healthcare.

In 2016, the Asia-Pacific Mental Health Integration Index by the Economic Intelligence Unit (EIU) ranked mental healthcare systems across 15 A-P countries, including Malaysia. The index included data on the number of psychiatrists, psychologists, nurses and social workers to build a composite score of the mental health workforce in each country. [2]

In that index, Malaysia was ranked below Pakistan and the Philippines, two low income countries. At the time of reporting, Malaysia also had roughly a quarter of the number of psychiatrists recommended by the WHO for an upper middle income country.[3]

Recent government statistics have equally shed light on this problem. From 2009 to 2013, psychiatrists registered the lowest increase among all categories of clinical specialists in Malaysia and in 2013, Malaysia had 0.13 psychiatrists per 10,000 population, far lower than the OECD average of 1.31.[4]

There is an even greater paucity of clinical psychologists, the other core branch of mental health providers.

Data quality is poor, since clinical psychologists are currently not regulated under the Mental Health Act and do not need to be formally registered. However, in 2011, a national workforce statistics report noted that there were merely 16 full-time clinical psychologists working in the public and private sector, while another 26 were visiting or part-time workers.[5] A recent parliamentary reply revealed that as of 31st January 2017, the job quota for clinical psychologists serving under the Health Ministry is capped at 15 and out of that, 14 positions have been filled.

Quality of treatment affected

In 2015, the National Health and Morbidity Survey reported a 29.2% prevalence of psychiatric morbidity for adults aged 16 and above, an almost three-fold increase from 10.7% in 1996 (children and adolescents reported a 12.1% prevalence).

Increasingly, more mental health-related incidents are appearing in the news. The reports range from rising workforce depression to more shocking incidents, like the case of a mother suffering from postnatal depression who took her child’s life, or an ex-convict who attempted suicide at a Monorail station in Brickfields.[6]

The nation’s escalating mental health needs signal a need for more qualified mental health professionals to deliver service. However, doctors are currently overburdened and have limited time to treat patients.

mental health workforce under pressure fig1

Figure 1: Number of follow-up cases at psychiatric outpatient clinics in government hospitals.

Source: Federal government budget sheets 2013-2017, B/P 42 (Kementerian Kesihatan).

Over the past five years, the number of follow-up cases seen at psychiatric outpatient clinics in public hospitals has risen steadily, from 525,000 cases in 2013 to 587,000 cases in 2017.

Based on doctor-patient ratios in these clinics, a psychiatrist would in theory have to see 13 patients in an 8-hour working day, with approximately 37 minutes to treat each individual.
This is arguably insufficient, as the nature of psychiatric work is typically time intensive. It involves lengthy interviews with patients and caregivers to collect a detailed case history, as well as delivering psychotherapy, a treatment approach that involves listening and communicating with the patient to help him or her build resilience and problem-solving skills.

Such work requires sufficient time to spend with patients in building and ensuring that the relationship is one of partnership rather than force.[7]

Scale up action to address critical workforce gaps

Since the 1970s, psychiatric care in Malaysia has moved from specialized institutions to decentralized outpatient, community and home-care services in the general and district hospitals. By distributing services in this way, the government has made good steps in enabling easy access to mental health treatment.

However, these facilities will be for naught if the workforce supply is insufficient to treat help seekers. As we have seen, there is currently a shortage across the board, and in particular, an alarming imbalance in the numbers of clinical psychologists.

To increase the supply of workers, the government should increase postgraduate scholarship funding for medical students who wish to advance a career in psychiatry and clinical psychology.

The Health Ministry should also make it compulsory for housemen to go on psychiatry postings during the Housemanship Training Programme, as a way to expose and encourage more to go into mental healthcare. Currently, it is just an optional module.

These are not quick fix solutions. It will take time and resources to implement policies. In the interim, the ministry should look into training GPs in primary health clinics to provide mental health care. As the first point of contact, these doctors are well placed to detect risk and refer patients to mental health services.
Singapore has already rolled out such programmes, and studies have shown that these have been effective in early detection of psychological problems.[8]

The Health Ministry should not tarry, but make haste in resolving the psychiatric workforce shortage. The mental health of the nation is at stake.

[2], p. 45
[3], p. 31
[4] Human Resources for Health Country Profiles 2015: Malaysia (Planning Division, Ministry of Health Malaysia) p. 13 and 16
[5] Clinical Research Centre National Healthcare Establishment & Workforce Statistics 2011, p. 89
[7] "Practice Guideline for Psychiatric Evaluation of Adults, Second Edition", APA Practice Guidelines, 2006, Chapter 1: Purpose of Evaluation. p.9.
[8] Lum AW, Kwok KW, Chong SA. Providing integrated mental health services in the Singapore primary care setting- the general practitioner psychiatric programme experience. Ann Acad Med Singapore 2008; 37: 128-31.

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